Page 42 - World Journal of Laparoscopic Surgery

Laparoscopic Intervention after VP Shunt
in cerebral blood flow, when the abdominal pressure reached The original shunting equipment was quite like a simple
15 mm Hg, and a rapid improvement was observed when the catheter. Soon after developing the shunt a no-reflow valve was
pressure decreased to 10 mm Hg. added. This design was effective and did not change significantly
Protecting the shunt from a potential reflux has always been a thereafter. The risk of a sudden rise in the ICP was possibly
concern; therefore, several reports have been published addressing overevaluated. 39
methods to temporarily protect the shunt during laparoscopic The only case of pneumocephalus was reported by Raskin et
36
procedures. al. He reported that the pressure used during laparoscopy was
There were several cases without any safety precautions 50 mm Hg in a patient with a VP shunt that was placed more than
being described, 1,8,17,20–26,32,34,37,39 but some surgeons used 20 years prior to the procedure. The authors of this article were
the following protecting techniques: clamping of the shunt contacted, and it reveals that this pressure was documented from
intra-abdominally, 19,29,38 clamping of the shunt through a skin an operation report written by the gynecologist and could not be
23
incision, externalization of the shunt before insufflation 10,27,30 proved again.
31
or intraoperatively because of the possibility of a peritonitis, The first reported complication was a respiratory failure caused
and packing of the shunt with a simple gauze, so that it is further by extensive subcutaneous emphysema after a laparoscopic
away from the operative field. 10,27 Two cases were reported with surgery in a patient who had a VP shunt placed shortly before the
38
15
patients who were diagnosed with cancer, where clamping and procedure. A severe subcutaneous emphysema developed during
intraoperative shunt externalization were the methods of choice. 27 the peritoneal insufflations of CO along a VP track created prior to
2
Some authors tried other methods to protect the shunts’ 10 days. This case report implies that a newly placed VP catheter
35
function. In 2011, Ghomi et al. reported a case of laparoscopic should be viewed as a relative contraindication to laparoscopy. This
hysteropexy, where the intraperitoneal pressure decreased from problem can be avoided by delaying the laparoscopy.
20
15 to 5 mm Hg every 30 minutes to minimize the changes in the The first case of shunt failure was caused by a distal shunt
ICP. This strategy was recommended as an option to prevent the obstruction due to an air lock or soft tissue impaction that was
possible shunt occlusions and a rise in the ICP. created during laparoscopic placement of a feeding jejunostomy
27
tube. The patient required an urgent reoperation to clear the
dIscussIon distal shunt. This could be avoided by checking the intraperitoneal
Laparoscopic surgery has become a preferred method of accessing end of the shunt, so that it does not get twisted or compressed.
and treating a variety of patients with intraperitoneal pathologies. There is only one case of robotic surgery (hysterectomy) and it
33
Given the fact that laparoscopic interventions are now being used was successful. It is an important case, because the Trendelenburg
in a wider range of patients, surgeons can expect to encounter position in robotic surgery is steeper and there is no possibility
patients who have undergone placements of VP shunts and who of changing the degree of the Trendelenburg position after the
present potential candidates for laparoscopic procedures. docking. In this report, the authors temporarily clamped the shunt
1
The first VP shunt implantation was performed in 1908. Schwed and the pressure throughout the operation was held at 12 mm Hg. 32
19
et al. described the first laparoscopic operation in a patient with Long-lasting laparoscopic operations in VP shunt patients are
a VP shunt in 1992. The observation of a high ICP in animal models still being discussed and operations that take longer than 3 hours
41
raised concerns about the safety of laparoscopy. In 1995, after are not recommended. 39
monitoring the flow of CSF in VP shunts intraoperatively with a An infection of a VP shunt is always an issue. Different studies
pneumoperitoneum pressure of 10 to 15 mm Hg, it was suggested proved that the shunt infection correlates with the number of
10
that elective laparoscopic operations in patients with VP shunts can exposures of the shunt system to a surgical glove. The specific
be done safely without the need of clamping or the necessity of advantages of laparoscopy in patients with a VP shunt may include
20
any other manipulation with the shunt. Despite some successful less intra-abdominal adhesion formation and limited glove-to-
reports, 16,17 the first intraoperative ICP monitoring was executed shunt contact. Theoretically these advantages of laparoscopy
18
in 1997. It showed a transient increase in the ICP during the should decrease the need for shunt revision due to the loss of
laparoscopy and raised some questions whether a routine ICP absorptive peritoneal surface and decrease in the risk of a shunt
10
monitoring should be advised. infection. 1,12 Allam et al. have shown that intra-abdominal
To determine the potential for back-pressure failure and operations appear to result in a shunt infection with the rate of
42
to observe the retrograde valve leaks, in 1999 Neale and Falk 9% within 30 days after the operation. The rate is like the reported
performed a very interesting experiment. An in vitro model was findings about infections after a shunt insertion or a shunt revision.
used to test nine forms of VP shunt valves and demonstrated that It is believed that a rational use of antibiotics can reduce the
none of the valves showed any retrograde flow when exposed to consequences of a CSF infection and decrease the likelihood of
11
pressure up to 350 mm Hg. The disruption in the seal on seven of a subsequent infection. 9,10 Burns and Dippe found that 53% of
nine shunts was, however, seen at pressure above 80 mm Hg. That postoperative surgical site infections are not identified until after
presents a level of pressure that is approximately seven times above the patient was discharged from the hospital. Therefore, educating
the maintained pressure during laparoscopic surgery. These findings the patients and their families about the signs and symptoms of an
were questioning the previous strategies of clamping or externalizing altered VP shunt function (like headaches and photophobia) that
the end of the VP shunt to minimize the risk of a retrograde flow and may result from a postoperative infection is recommended. If the
were suggesting that these manipulations could possibly result in an patients can recognize the symptoms of an infection after being
increase in the ICP due to the blockage of normal CSF flow. discharging from the hospital, it could prevent potential serious
Five different valves simulating a closed system were studied complications. 2,11,15 A preexisting VP shunt often causes clinically
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by Matsumoto et al. in Japan in 2010. There was no reflux of the significant intra-abdominal adhesions, and these can lead to a
CO for any of the valves with a pressure of less than 25 mm Hg. 8 higher conversion rate. 10,21,36
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40 World Journal of Laparoscopic Surgery, Volume 13 Issue 1 (January–April 2020)